Nursing Elites

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?

• A. Thoracic deformity
• B. A bunion
• C. A corn
• D. Metacarpal involvement

Correct answer: B

Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.

3. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

• A. Avoid contact sports until the infection has cleared
• B. Use a bath sponge to cleanse the skin
• C. Wash hands with soap and water before and after touching the infected area
• D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

4. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

5. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

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